Sample_Application_for_Payment.pdf

This is a Sample Application for Payment form used by Pinellas County Department in Florida for processing contractor payment requests on public works projects. The form serves as both an application and certificate for payment submission, designed to document financial transactions between contractors and the County throughout the project execution period. The document captures essential payment information including the contractor name, purchase order number, payment period, and change order summary detailing any modifications to the original agreement amount. The application requires certification that payments are used in accordance with contract terms and that previous payments have been appropriately applied to materials and work performed. The form designates approval authority to the Consulting or Design Professional/Engineer of Record and the respective Department's Engineering Project Manager.

The payment application incorporates retainage provisions, with a designated percentage withheld from earned amounts pending project completion and satisfactory performance. Upon payment authorization, the contractor provides a statutory release waiving all claims, demands, damages, and costs against the Board of County Commissioners of Pinellas County and Pinellas County Public Works for the specified contract period. This release extends to subcontractors, materialmen, successors, and assigns, effectively settling all contractual and tort-related disputes associated with the performance agreement. The form requires signatures from both the contractor and County representatives, including the Engineering Project Manager and Department Director, establishing accountability and authorization for fund disbursement.